106 – Hormonal acne, hair loss & ageing skin with Dr Saj Rajpar

0:00So today on the podcast I'm very excited to reintroduce to you Dr Saj Rajpar who is the most amazing dermatologist, skin specialist extraordinaire who I know very well but respect a lot as well. So we talk a lot about skin, what the skin is, what it does for us, what hormones in the skin do when hormone levels are changing and also about Saj's rather unique clinical practice as well. So listen, share, enjoy. Welcome, Saj, to the podcast. I think you're my most frequent guest, actually. I think you've just topped a couple others because I think this might be your fifth time even. Well, that's a fantastic statistic and it's a real pleasure to be invited back.

0:48It's always lovely to speak to you and actually learn from you during our podcast. Well, do you know what? We've learned a lot from each other over the years and it's probably been about six or seven years maybe that we've known each other and let's go back to how we met really because for those listeners that don't know Saj is a dermatologist works and runs Midland Skin in Birmingham and you wrote me a letter about one of our patients we had a mutual patient who had hair loss and I've been very used to getting letters from other specialists that are just one-liners and they say all these weird and wonderful treatments that may or may not work with nothing else.

1:28Whereas your letter was incredibly detailed with all the different investigations you'd done, all the ways to try and exclude other medical causes. And you were also sort of really keen to have a dialogue about the role of hormones and hair loss. And I think I might have emailed you or phoned you and now we've got this lovely relationship. But I think that's right, isn't it? Yeah, it's absolutely brilliant that a patient brought us together and we are here to serve our patients and you know we just wanted to get that person the best possible outcome from medical treatment yeah and yeah it was great because we connected and we exchanged ideas and this patient was experiencing hair loss and it was trying to connect the dots as to what a massive impact this patient's perimenopause was having on her hair loss and how eventually optimizing her hormones was one of the cornerstones in treating her hair loss.

2:30And had we not done that, and had you not done that, in fact, you know, we would not have got the outcomes from the rest of her hair treatments that we did. And because it was that collaborative care and it was understanding that you know it's not just one solution there could be more than one thing going on you've got to address that you've got to identify it you know that's good medicine isn't it it's kind of work well it's really it's really important to really be holistic in in our care whatever strand of medicine we do but you're a dermatologist so for those people that don't know what dermatology is can you just explain what it means being a dermatologist yeah it means a lot of things actually.

3:12To me, it means somebody who has a medical degree, who's medically qualified, and has specialized in the diagnosis and treatment of disorders and conditions affecting the skin, hair, and nails. And those treatments might be medical treatments, They might be surgical treatments or they might be procedural treatments with devices such as lasers that we use for medical indications. And a dermatologist may treat adults and may treat children as well. Yeah. It's really interesting because this is what's really important. Well, there's lots of important things, but dermatologists are medical doctors.

3:59So you've had the same medical training as me. And you also usually, dermatologists have done different medical specialties before going into dermatology. So a lot of people have done other areas of medicine, haven't they? Yeah. So it's really important to have your foundation in medical practice, but also expose yourself to various other specialties because the skin does not function in isolation. and if you're not aware and the same with you Louise you've done you know jobs across several medical specialties and I know cardiology and cancer medicine and so many others and it's really important to get that grounding because things come through the door that if you can't rely on your basic medical knowledge you'll never pick up because the skin is the external visualization of many internal problems.

4:53You can see, you know, things like hormone deficiencies, like menopause and perimenopause in the skin, but you might see thyroid hormone deficiency in the skin. You might see cortisol deficiency first on the skin. You might see iron deficiency on the skin. You might see diabetes on the skin, you know, for the first time. So there are a lot of systemic conditions that present on the skin. And the other thing is that dermatology has become more and more complex and medications available in dermatology have become more and more sophisticated. And you cannot deliver those medications if you don't have an understanding of physiology, the kidneys, the liver, the blood system, and how all those things interact, especially if somebody's got other comorbidities.

5:41That means they've got other conditions or other medications that they're taking. And that transcends across all aspects of dermatology, really, even procedural dermatology. You've really got to understand how you might treat something. You know, I might see somebody with skin lesions because they've had a kidney transplant and they're on a medication from that kidney transplant that's causing those skin lesions. And I might need to have knowledge and oversight of that in order to best treat them. So, you know, everything works together. And that's really crucially important because, Because, you know, medicine's become even more siloed than it was.

6:16I mean, I'm older than you, but when we were training, we did a lot of, even as undergraduates, we saw a lot of specialties. We were constantly exposed to different specialties. And then when we were doing our exams to be a member of the Royal College of Physicians, we did lots of different specialties. And when we were on call, we'd see anybody that would walk in or be stretched in. So we weren't selective in what we saw. So you had to join the dots a lot more. So if someone was in liver failure and their skin was yellow and they had bruising on their skin, that was spontaneous. Then you think about alcohol, you think about cirrhosis.

6:53So you're constantly got these differential diagnosis going on. But sometimes in medicine, and the two specialties that I deal a lot with, which frustrate me a lot, are gynecologists and psychiatrists because gynecologists seem to think they own hormones because they come from the ovaries, but they also come from the brain and other tissues. but gynaecologists go straight into gynaecology they don't have the beauty of being able to have all these other postgraduate experiences that we have as junior doctors the same as psychiatrists who obviously mental health is is the commonest um sort of um one of the commonest symptoms of hormonal change are mental health symptoms and psychiatrists tend to go straight into psychiatry training so they become very siloed very quickly whereas i think people forget with dermatology, but you are often using the skin as a window into the body because the skin is an organ.

7:47It's not just a protective layer. And it's certainly not just how our face looks because I was talking to my husband recently and we were saying it's really hard now to see how old people are because they all have cosmetic treatments. Very few people have lines anymore. And it's really difficult to know, is this person a dodgy looking 60 year old or are they really 30 you know it's really hard but when you look at their whole body obviously you you know a lot more but dermatology has to always look at the bigger picture and look about think about the organs and and what else is going on don't you absolutely absolutely you've got to as you said connect the dots and say take something as simple as itch.

8:32You know, the cause of itch, there's a list as long as my arm. And if you're not familiar with the, you know, the body, the physiology of the body, how to investigate different aspects and different organ systems, you may miss potentially important causes. And, you know, common causes of itch might be skin disorders like eczema and psoriasis and hives and urticaria. But internal conditions like iron deficiency, thyroid disorders, and even cancers, some lymphomas. And in fact, in my career, I've diagnosed one young person with lymphoma who actually presented with itch. You know, when an 18-year-old comes in and is itching all over for no particular reason and has never had any skin history, you've got to put your diagnostic hat on and say well this is rather odd you know what's going on here and this person had been through several doctors had had treatments for eczema and scabies which is the obvious typical thing that everybody jumps to but when you take a history and you say oh well you've got night sweats you're not you know feeling great and then you examine them and you check other parts of their body you check their lymph glands you check their liver you know That's what we're trained to, aren't we?

9:55We're trained as diagnosticians. We don't have a scan in our room. We don't have blood test machines in our room. We've just got our eyes and our hands and our ears, and we've just got to kind of put it all together. And it's very similar to what you're doing. You're seeing patients and women with multiple symptoms, and you're trying to figure out where are these symptoms coming from. Yeah, it's totally true, and I've written quite a lot about it in my book, The Power of Hormones, is that we have to listen to our patients. And, you know, I'm the same as you. We didn't have training about menopause, hormones, when we were undergraduates or even, you know, when we were junior doctors, which is very frustrating.

10:35And I think back to a lot of my patients I saw in general practice who did come in with itchy skin. And a lot of them were women. And I did all the usual checks, make sure their liver, their kidneys were fine, they didn't have iron deficiency, their thyroid was fine. and I never once thought about their hormones and now my work is obviously not just menopause either so I see a lot of women with PMDD, premenstrual dysphoric disorder, PMS, premenstrual syndrome but also increasingly we're seeing a lot more people in my clinic with postnatal depression and I see a lot of women who've had postnatal psychosis as well and one of the things that we always do as you know with every patient is we give them the symptom questionnaire which is the same as the one on Balance app.

11:18And it asks all sorts of symptoms, including there's a whole section on skin. So dry skin, itchy skin, acne, any skin changes. And usually, not always, but usually people with PMS, PMDD, postnatal mental health, if you ask them specifically those questions, they will say they have skin changes before their periods. But if you're not joining the dots and I never used to, I would be concentrating on the symptoms a woman was complaining of because it's so accepted that it's just a hormonal change of skin. But actually, it's the body again saying something internally is out of balance and it's the hormones.

11:59And it's really important. Do you see that much in your clinic where people have skin changes throughout the cycle? This is so interesting to me because we see a huge number of women with hormonal acne. And, you know, it is so common for women to come in through, you know, their adult life to us saying, you know, ever since I was 11 or 12, you know, in the week just before my period, my skin completely changes. You know, it'll go greasier or drier. I'll have more bumps and texture. usually that means comedones and I'll break out typically along the chin and the jawline but anywhere you know anywhere on the face the neck and the back and it is you know a reason for which many women struggle because it's something that just does not always easily come under control many women will have tried synthetic combined hormones yes you know and this is so typical they'll come in and say you know i'd say about 50 to 60 percent of women will say it didn't work for me or it made my skin worse that's combined contraception and then many others will say look yeah it helped my skin but my god my mood my weight you know all these and i just don't want to you know i really don't want to go back on that um can you help so and and the other sort of time that we see this issue with acne is in the perimenopause.

13:37It's very similar. And often the same women will say, you know, I've only just had five or six good years with my skin, and now it's started all over again. And the first thing I do is I say, and I would never have done this, Louise, had I not met you or understood or learned and come to your conferences and courses and done the online course myself. The first thing I ask is what's happening with your hormones yeah and it's kind of like the penny then drops and they're like well actually nobody's asked me but you know this is happening that's happening and it's like you know before I give you another acne cream or another you know acne directed treatment let's talk about optimizing your hormones and you know can you go and seek help on that yeah get your hormones figured and then come back to me and then we'll pick up where we've left you know where you're at then and it's been a game changer and I really I would encourage all my colleagues you know who are seeing skin to try and think critically about you know what's going on in that person in their hormonal situation it's so important and and I worry I worry a lot about every woman but I worry a lot especially about younger children girls young adults who have these skin changes and And sadly, I used to do it as an uneducated GP.

15:00I used to prescribe the contraceptive pill because I thought it was skin friendly. And some of them are marketed as being skin friendly. And they, like you say, they might help. But then in medicine, we have to think about the root cause and what we're doing. So synthetic hormonal contraceptives do not contain hormones. They contain substances that block hormones. and even a very commonly prescribed progestogen, synthetic progesterone called mejoxyprogesterone acetate, actually works as an aromatase inhibitor. So it blocks the action of estradiol on the skin, in the brain, and every other organ in the body.

15:37So I'm sure you've seen people who have the Depo-Provera injection and their skin completely breaks out. And I always, when I was younger, thought, oh, progesterone's bad for the skin because it's called mejoxyprogesterone. so you think it's got progesterone in it. If you look at the chemical structure, it's not progesterone at all. It's a synthetic chemical. And then when you read it, I mean, there's great articles from the 80s and 90s showing how it blocks the action of oestradiol. We know oestradiol, which is a good anti-inflammatory form of oestrogen, is very beneficial on the skin. It helps build collagen.

16:11It helps the blood flow to the skin. It helps the skin texture, everything. So it's such a shame that people are blaming hormones when the right bioidentical hormone can be transformational. Yeah. Well, this is really interesting because it was just the other week where I saw one of my patients with acne who's been stable for years on treatment and her acne destabilised. It's a lady in her late 40s, early 50s. She'd had perimenopause and menopause about seven years ago. So she was already on hormone replacement at this point, very stable. And her acne broke out. And we're trying to figure out what has changed.

16:59And she was asked to switch from her oral bioidentical progesterone to the Mirena Coypac. Yeah. So that's all that had happened. And nobody thought anything of it. This had been going on for her acne flare had been going on for at least nine months. And we were just trying to backtrack on what could it have been when this person was so beautifully controlled. And I mean going from very severe lifelong chronic acne to brilliant control. And it was that. And it was such an eye opener because it's marketed as something that is local. You know, there's not going to be any systemic spread. You're not going to have any side effects anywhere.

17:41Well, that's not true. Well, I've seen it a lot. And it's very interesting because I used to tell patients again that Mirena Corle only works locally in the womb. But let's think about it. Our womb is very vascular. It's got lots of blood vessels in it. The blood vessels connect with every other blood vessel in the body and brain. So there's not a Teflon sheet around the womb. So, of course, this synthetic progesterone, it's a low dose. but for some women are very sensitive, are going to have this effect. And I see people who have severe mental health problems with Mirena, but also skin changes as well.

18:13And we have to be thinking about the difference between the natural bioidentical and the synthetic hormones all the time. And patients sometimes don't know the difference and they'll tell you they're on a progesterone and they're often not. But I'm going to ask you something that I know last podcast we got lots of views about, about using topical hormone preparation. So these are vaginal hormone preparations. So I'm not talking about systemic estrogel, but some of the estradiol gels and creams, quite a few people use them on their faces intermittently. And there is small data to show it will help, but there's logical data.

18:51Like anything that I put in my vagina or on my vulva is going to help the blood flow. It's going to help circulation. It's going to help the tissues. we know that you know it's very repairing these things and what I'm wondering and I don't know the answer here and I don't think you will what if someone used a low dose vaginal oestradiol or oestradiol cream or gel preparation on their acne on their face like it might have an effect we don't know do you know that's potentially a very interesting idea to to look at because recently a topical preparation has been licensed in the UK that blocks testosterone.

19:34Now, you know, that might not actually be the reason why somebody is breaking out. It might be because of the exposure to estrogen has dropped, leaving whatever the balance between estrogen and testosterone, you know. And so what we're doing now is we're saying, oh, let's drop your testosterone what we haven't understood is actually the primary reason was the estrogen and progesterone had dropped and that's why you're getting your parent you know the flare in the week before your period so can you put the estrogen back topically rather than block the testosterone topically and it's a bit like yeah it has merit doesn't it so women with um pmos which used to be PCOS.

20:16Everyone's always blamed the testosterone, whereas in fact, and I've done a YouTube about it, people with PMOS often have low estradiol and low progesterone. So relatively speaking, their testosterone is higher than their other two hormones. We always used to block the testosterone and a lot of people still do with people with PMOS and those people often feel dreadful. But in our clinic, we often give them systemic estradiol and progesterone and they feel amazing and their skin improves because they're having systemic hormones, their mental health improves, they have more regular periods if we give them the right dose and time for progesterone.

20:52So we know systemic hormones work and there are some people that do use low-dose oestradar but also low-dose progesterone cream topically on their skin. But people seem really scared of that. I don't have a problem with it at all because sometimes in medicine you try something with a logical reason and then you have a review. One of my sort of reservations is we shouldn't just be looking at the face. And I worry if we're only putting something on our face, if it's PMOS, which is a metabolic problem, we need those hormones systemically because estrogen and progesterone are very good, as you know, for insulin resistance and metabolism and so forth.

21:31But I think we should do a study. I think we should look at this more because actually there's a lot of preparations that girls, women are spending fortunes on, including my children over the years have done. And if a low-dose oestradiol was going to help a little bit, they would love it, rather than going for Roaccutane or something else. So it's something to think about, isn't it? And absolutely, it's something that also would be a treatment that could work in the medium to long term, Whereas a lot of the acne treatments that exist may not have, you know, durable results. In other words, you know, Roaccutane doesn't always clear somebody's skin and their skin doesn't always stay clear.

22:12So you do need to have something else. And if it is a hormonal basis to somebody's acne, then looking at the hormones and, you know, it's a fantastic idea, Louise. And, you know, this is how treatment of conditions will move forward, isn't it? Well, it's interesting. And I constantly think, partly because I've got three daughters, and contraception is really difficult because every single hormonal contraception contains synthetic hormones. We do have Zoli, which contains estradiol, but it contains a synthetic progesterone. And often I will add back natural bioidentical progesterone to people who have Zoli as well.

22:50But sometimes they still have breakouts in their skin. And so it's just something to think about. But there are so many different treatments. And one of the things I worry about with dermatology, not with you, I hasten to add, but I see that come up on my Instagram and they're often advertised in different, even shops and department stores now seem to have dermatologists that do all these high end, very expensive treatments just for the skin. And often they involve lasers and injections and all sorts of treatments. Some of them look quite painful. But I worry that it's just a skin deep thing. It's just looking at an immediate result.

23:31And I've been to your clinic several times, lots of my patients have. You have loads of lasers, but I've never seen you do it just for a pure cosmetic. It's more than, I mean, you're always analysing the skin and you do a lot with melasma. We've done a podcast about that and different skin conditions. So tell me where these high-end treatments, if you like, because I can see the appeal for some people, but I'm really worried about how they're just, anybody can go and have a bit of laser or something. So tell me the difference. Yeah, I think it's really interesting that you point out that you're seeing these treatments being delivered on the high street and in department stores now.

24:13And I just point out the fact that dermatologists as the title is not even protected. So that means anyone, whether they're medically qualified or not, can call themselves a dermatologist. So you will hear the terms cosmetic dermatologist, aesthetic dermatologist, laser dermatologist, all sorts of terms, and people trying to use authority to sell treatments. And so I would encourage anyone to first, you know, just know who they're being treated by and what their qualifications are. Lasers are interesting. I find them fascinating. I did my very first laser qualification in 2003. That's 23 years ago, before I even got my first job in dermatology, my first very junior SHO job.

25:14And I know at the interview they said, my God, you've done this B-tech in lasers. Many of our registrars haven't done that. And I said, look, I really am fascinated by the physics of lasers, but also how you can harness that energy and actually have positive impact on the skin for medical concerns as well as aesthetic concerns. But there are a huge list of medical concerns that lasers work for, like melasma, as you mentioned, or rosacea or acne, and really importantly, scars, whether they're post-surgical scars or burn scars or keloid scars. So there's a whole host of medical reasons why doctors like myself use lasers.

26:01And lasers knowledge is getting better and better, and the machines are getting better and better as well, so the outcomes are getting better and better. And there is definitely a role for lasers in facial rejuvenation for the right candidate at the right time. And I think the key thing here is making sure it's the right candidate. And I saw somebody, you know, week before last who came in for a heavy laser treatment consultation. And it turned out that her skin aging happened in the five preceding years. And that was around the menopause. Quite dramatic, quite dramatic skin aging, you know, more profound than you see on average.

26:45Now, we know we lose 30 % of collagen, or women can lose 30 % of collagen in the first five years after menopause. But this looked, you know, very much 30 % plus. And I thought, gosh, this is, you know, we know things are in a normal distribution, aren't they, in medicine? And, you know, most people are bang in the middle, but there will always be some outliers. And I thought, gosh, this is an outlier. And the timing here does not fit with general chronological aging with some menopausal changes if their estrogen hasn't been corrected. And really, that person wanted laser, wanted a solution. And I actually said, no, you're not suitable.

27:25This is not the right treatment for you. You're not the right person for this. Optimize your hormones. And I actually wrote a referral to you guys straight away. That's amazing though. And I said, yeah, you know, that is your priority here. And, you know, the sagging issue as well, facial sagging, and the fact that women's faces change in a different way to men's faces around the menopause, where, you know, jaw bone, which is the lower facial bone, mineral density goes down a lot quicker, and therefore the skin sags more. There's a lot of, you know, changes that are happening at that point. And really, you can't necessarily just cover it all up with a laser treatment or a surgical treatment.

28:06You really want to get to the root cause, as you mentioned. Absolutely. And there's no harm at all for having rejuvenation, having treatments, but it's looking at the underlying cause. And I think if there's one thing for people to learn from this podcast is if you're seeing a dermatologist, don't look at the title. Don't even get hoodwinked by doctors because a lot of them might have only done one, two years as a medical doctor. look at their ask for their CV see what experience they have and make sure that you're treated really holistically and and Saj and I relationship professionally is very very close because I need help often with people with hair skin nail problems that only an expert dermatologist like him can help and he often needs help with our clinic with the hormone balance and the two together can really transform people's lives and future health so don't dismiss skin but make sure you see someone who's really experienced.

28:59So I'm very grateful for your time because we're recording this on a Saturday morning and Saj is a bit like me. He doesn't often switch off because he's constantly working and helping people, which is what we went into medicine for. So before I end though, Saj, I always ask for three take-home tips. So I'm going to ask you three reasons why the skin is the most important organ in the body in your eyes. That's a good question, Louise. the skin is the most important organ because if you look after it it will treat you very very well and it's very easy to look after and that starts with looking after yourself with your diet your lifestyle you know not smoking sun exposure those things will pay dividends and the third one is what we touched upon before which is the skin is a window to your body and if there's something that's not right with your skin, then getting it checked out can reveal and help you with problems that you're experiencing in the body.

30:04Perfect. So what we're trying to say is don't ignore the skin and make sure if you're treating the skin, you're looking internally as well. Because as doctors, we need to be as holistic as possible and multi-system approach is always going to help. So thank you again for your time, Sajj. And I don't think it's going to be the last time that you're coming on to this podcast so thank you thanks louise it's always a pleasure